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Westminster Hall

Volume 638: debated on Thursday 22 March 2018

Westminster Hall

Thursday 22 March 2018

[Graham Stringer in the Chair]

Improving Air Quality

Environment, Food and Rural Affairs Committee, Environmental Audit Committee, Health and Social Care Committee and Transport Committee

Select Committee statement

We shall begin with the Select Committee statement. Neil Parish will speak on the publication of the joint report “Improving air quality” for up to 10 minutes, during which time no interventions may be taken. At the conclusion of his statement, I will call, in order, the Chair of the Environmental Audit Committee, the Chair and the Health and Social Care Committee and the Chair of the Transport Committee.

Other Members may then put questions to Neil Parish. I will call him to respond to each of those in turn. Members can expect to be called only once. The Select Committee Chairs will be given more time, but if they can formulate their statement in the form of a question, that would be helpful. I now call the Chair of the Environment, Food and Rural Affairs Committee, Neil Parish.

Thank you, Mr Stringer. It is a great pleasure to serve under your chairmanship, I think for the first time. It is good that you had the benefit of being on the Joint Committee during the inquiry. I assure Members that I will not speak for 10 minutes, so as to allow more time for questions. I thank the Backbench Business Committee for facilitating this statement on our recent report, “Improving air quality”.

Before we begin, I am reminded that a year ago my Committee was taking evidence from the Minister when we were called to a Division. The unthinkable happened. We all stand here today because of the unflinching bravery of those on the frontline, in particular the courage of PC Keith Palmer. We carry on our work and we are all here today because we remember the great sacrifices that have been made to enable us to do so.

Clean air is a right and not a privilege. We launched a joint inquiry in October last year to examine the Government’s latest air quality strategy and whether it was adequate. I thank my fellow Select Committee Chairs, my hon. Friend the Member for Totnes (Dr Wollaston) from the Health and Social Care Committee, the hon. Member for Nottingham South (Lilian Greenwood) from the Transport Committee and the hon. Member for Wakefield (Mary Creagh) from the Environmental Audit Committee. I think we worked remarkably well together. I also thank the Committee staff for all their hard work in bringing it all together.

For too long, the United Kingdom has failed to meet legal air quality limits. That is simply not good enough. It was clear to us that Departments must work together to address this national health emergency. My fellow Chairs and I launched the joint inquiry to show that if we can work together, so can Government. We took evidence from expert witnesses, the Mayor of London, Ministers from the Department for Environment, Food and Rural Affairs, the Department for Transport, the Treasury and the Department for Communities and Local Government. It was clear to us that the Departments are not doing enough to protect the public from toxic air.

Poor air quality costs the UK some £20 billion a year, and it is a huge public health risk to all our constituents. Because of the failure to collaborate and to come up with an effective strategy, the Government are letting us down. Car manufacturers have contributed towards poor air quality for too long, and the Government have allowed that to happen and let them—in my opinion—off the hook. From the USA to Germany, car manufacturers have contributed millions of pounds to cleaning up their air. Why have we not had that contribution in this country?

Councils struggling with air quality need more leadership from Government to ensure that they have the resources to tackle the problem effectively. The Government must work more closely with councils to roll out vital infrastructure, especially electric vehicle charging points and fast-charging points. That would also help small and medium-sized enterprises and others if they wanted to convert to electric and hybrid vehicles, so that they had the charging points as well as the drivers.

All that must be included in a new clean air Act, which would concentrate the resources we so desperately need to clean up our air quality. A refusal to act is simply passing the buck. Our children and grandchildren deserve better. The Government should implement our recommendations and give us all the right to breathe cleaner air. I look forward to the Ministers’ responses to our report.

I echo the hon. Gentleman’s sentiments about this being a very solemn day for this place, when we remember the five victims who so tragically and suddenly lost their lives. In particular, we hold in our hearts PC Keith Palmer, who stood his ground, not 50 yards from this room, to defend this place and to defend our Parliament. The debt of gratitude that we owe him and his family can never be repaid.

One of the interesting things that came out of the inquiry was the huge and developing evidence about the impact of air pollution on health and health inequalities. Does the hon. Gentleman agree that a worrying piece of evidence that came out of the inquiry was research from the Royal College of Physicians showing that air pollution could reduce children’s birth weight and damage IQ, and that it was possibly an increasing factor in lung cancer for people who have never smoked?

I agree passionately that we need a new clean air Act. The Environmental Audit Committee has been looking at the accountability mechanisms. We need an environmental protection Act to set up an accountable body so that that mechanism is still in place if and when we leave the EU. The clock is ticking loudly on that. Does the hon. Gentleman agree that the Government need to speed up their activity in that area?

Does the hon. Gentleman agree that we need to adopt the World Health Organisation’s targets for all air pollutants, not just nitrogen dioxide, and to set out clear milestones for meeting them? It is all very well saying that it will happen in 10 or 15 years’ time, but if we do not have milestones, they will not be met.

Does the hon. Gentleman agree that the Government need to do much more on central Government procurement? They have said that 25% of Departments’ car fleets will be ultra low emission vehicles by 2022. We have just completed an audit of the Ministry of Justice. Of 1,500 vehicles, just two are ultra low emission. The Department for Environment, Food and Rural Affairs has only two electric vehicles in its fleet. The Government need go much further and much faster, and to extend that target to outside agencies, including the NHS, because its carbon footprint is huge.

Does the hon. Gentleman agree that the cheapest and simplest method is to label vehicle emissions on new cars so that when a person goes into a car showroom, they know exactly what they are purchasing? That would mean that they could future-proof themselves against any action that might be taken by their local authority or by the Government, so they were not buying something that may lose its value in two or five years’ time.

I thank the hon. Lady for her questions and, again, for her co-operation in putting the Joint Committee together. She will not be surprised to know that I very much agree with her points.

On the clean air Act, that is something we need the Government to come forward with, because it would concentrate not only resource but political drive on cleaning up our air. On the World Health Organisation’s targets, we need to be more ambitious than the Government are at the moment. On an environmental protection agency, we need to know more from the Government about how that would come about, how it would take on the role that the European Commission has had, and who could take the Government to court to hold them to account.

The car fleet is an interesting one. I expect that the hon. Lady, like me, has often come through Speaker’s Court and seen interesting vehicles waiting for Secretaries of State. The vehicles are all quite large, and as far as I can see very few have anything hybrid about them, so perhaps the Government could lead by example. It will be interesting to see what they do. This is a serious point, because as we get our new fleet of vehicles across all Departments, we need a series of electric vehicles and hybrids. For some places, all-electric will work. If people have to go longer distances, hybrids are essential. We look forward to working with all the other Select Committees to ensure that we deliver cleaner air.

I, too, pay tribute—I am sure I do so on behalf of the whole House—to PC Keith Palmer and the other victims of the terrorist attack a year ago today. I thank all the security staff who are on duty today, enabling our democracy to carry on functioning.

Does my hon. Friend the Member for Tiverton and Honiton (Neil Parish) agree that the list of illnesses caused by poor air quality is shockingly worrying? It includes, but is not limited to, respiratory illness, heart attack, hypertension, chronic obstructive pulmonary disease, asthma, dementia, type 2 diabetes and obesity. It is quite a long list, and the public probably would not suspect that all those illnesses link back to poor air quality.

Does my hon. Friend also agree that car users, who are sometimes seen as the source of the problem, are actually very serious victims? One of the surprising things that we learnt from doing our report was that people who regularly travel in cars in cities are themselves among those worst affected by poor air quality. Parents driving children to school in cities need to understand what the health effects are on them and their children.

Does my hon. Friend share my concern at what is frankly the absence from the pitch of the healthcare sector in a lot of the debate? We need to see a lot more action from Public Health England and from GPs, informing the public about the risks and telling them what to do. If I go into my local surgery, I will see advice on how to reduce smoking, on how to drink less alcohol and on weight reduction, but despite looking very hard I will not find anything to tell me what I can do to avoid poor air quality and how to deal with that issue.

Does my hon. Friend agree that if the health sector and those responsible for public health put that information out in a way that is helpful and useful to the public, that will help to bring about an army of concerned citizens who will demand change, at both local and national level, to deal with the problem?

I thank my hon. Friend for so ably representing the Health and Social Care Committee in our Joint Committee. He raises interesting points about the number of illnesses attributed to poor air quality. Of course, we were suddenly told to drive diesel vehicles because we needed to reduce carbon, ignoring the nitric oxide and the particulates. That is now hugely affecting our health. He talked about what is happening outside our schools and inside our cars—we are being affected by particulates even as we drive along.

My hon. Friend made a particular point about schools, and I think that this issue applies not just in the inner cities but everywhere. I say to parents, “When you come to pick up your children, please don’t leave your cars ticking over outside, with all the levels of pollution that causes.” That is really important across the whole country, not just in the hotspots of very poor air quality.

On the point about Public Health England, we do need much better and much more information about how poor air quality affects our health. That would also raise public awareness of what we are doing as we drive, how we drive and what we drive. It would bring those issues home to people as they make their choices in future.

During the inquiry, my hon. Friend was keen to ensure that our air quality monitoring systems, both in local government and the national systems, work together so that we can collate the figures, to ensure that we get better air quality, and really drill down to find the worst affected areas. Overall, we can all do more to reduce the amount of pollution we create. I thank him for his question.

I will try to keep my remarks short, to enable other hon. Members to ask questions. I associate myself with the comments paying tribute to and remembering PC Keith Palmer and those other members of the public who were killed or injured one year ago today.

The Chair of the Environment, Food and Rural Affairs Committee was absolutely right to highlight the need for joined-up action, across Departments and in a shared responsibility with local authorities, as we set about tackling pollution. It is absolutely essential that the Government show leadership and ensure that all their policies, including taxation and spending policies, are working in concert, not at cross-purposes.

Moreover, does the hon. Gentleman agree that if action to accelerate the take-up of less polluting vehicles, whether cars, vans, trucks or buses, is accompanied by measures that change behaviour and enable and encourage more people to walk, cycle and use public transport, there is a real opportunity not only to tackle air quality, but to meet the Government’s other objectives, including cutting carbon emissions, reducing urban congestion and raising physical activity levels?

I thank the hon. Lady for a great question and for her co-operation and work through the Joint Committee. She is absolutely right about reinforcing the fact that the issue is cross-departmental, because DEFRA is in the dock every time there is a court case, yet much of the solution is in transport and local government as we go about our daily lives. I went to Waterloo the other day to see the electric buses there. If we can get more electric buses across the whole country, that will really help.

With regard to the types of vehicle that we will use and their availability—the hon. Member for Wakefield (Mary Creagh) also raised this—we have to be absolutely certain that we know what vehicles we are buying and that they are properly labelled. Hydrogen vehicles might also be a solution in some places. We have to look at all these things and improve public transport across the piece. We also need to consider the way we run our lives. When we go shopping, for example, ideally we should go to the shops on the bus or on our bicycle, or sometimes shop online, and then all of it would be delivered by vans that were either hybrid or electric, not diesel. There are lots of things we can do not only across Government, but in the way we run our lives. I thank the Chair of the Transport Committee for her contributions.

Thank you, Mr Stringer, for allowing me to raise one point. This is a very strong report. In particular, it calls for a new clean air Act. I ask the Government to acknowledge that the report, with its strong recommendations, is based on a consensus between four Select Committees. I hope that they will take heed. Will my hon. Friend, who has made a brilliant introduction, join me in celebrating the appearance this very morning of a 100% electric, fully British-made black cab right here in New Palace Yard, of the sort that we will see flooding our streets in the years to come?

I thank my hon. Friend for that question. He reinforces the need for all of us to work together across Departments. The black cab out there that is 100% electric and 100% British is a very good thing. As I said, we can all welcome that, whichever side of the Chamber we sit on, because we need more of these taxis and we need more of them to be made here.

Order. We are running out of time; there are two minutes left, if I am to stick strictly to the 20-minute limit. I ask hon. Members to be brief.

I will be brief, Mr Stringer. May I add electric bicycles to the list of electric vehicles? They offer a huge opportunity to make a quick transformation.

I associate myself with the earlier remarks. May I ask the Chair of the Select Committee why he has not yet looked at the impact of the waste industry on air quality? It is an important industry and needs to be factored in.

We did not look at it directly in the joint report, but we have looked at it in previous Select Committee inquiries. I assure the shadow Minister that we will look at it in future, because it is all part of reducing our emissions.

My concern, as a representative of a midlands constituency bounded by motorways, is motorway pollution. It is certainly a problem for people living in Hinckley.

Again, motorway pollution is very much down to the vehicles that we drive. As we get cleaner petrol and hybrid cars, and even cleaner diesel cars—although we need to move away from those—that will help to reduce our overall pollution. It is absolutely essential that vehicles on motorways become cleaner.

Does the hon. Gentleman agree that there was an extremely high level of cross-party consensus on the report, and that we actually deliberated very carefully? It was extraordinary how few party political differences there were over its recommendations.

The hon. Gentleman is a very good member of the Environment, Food and Rural Affairs Committee. Yes, it is right that we have worked together, and it is right that all political parties now work together to produce cleaner air, because that is a right and not a privilege. Having two Chairs from either side of the political divide also helped; I think we all worked very well together. I again thank everybody for that.

Backbench Business

Leaving the EU: NHS

I beg to move,

That this House has considered the effect on the NHS of the UK leaving the EU.

It is a great pleasure to serve under your chairmanship, Mr Stringer. I thank the Backbench Business Committee for supporting the debate and the thousands of our constituents all over the country who pressed for it.

The debate is very timely. We are hopefully on the brink of a formal agreement on a transition deal, which will, over the next few months, very much set the scene for the vital negotiations on our long-term future relationship with the rest of the EU. It is also extremely timely given yesterday’s publication of the Health and Social Care Committee’s second report on the impact of Brexit on our health and social care system. I thank my colleagues on the Committee for the work they put in and all the individuals and organisations that provided us with invaluable evidence.

As you will remember, Mr Stringer, the NHS featured prominently in the EU referendum campaign. We well remember the famous—or infamous—bus that was taken around the country promising £350 million extra for the NHS if we left the EU. Most commentators, and several leave campaigners themselves, have credited that since discredited claim with taking the leave campaign over the line. Our health and social care systems also face one of the most significant impacts from Brexit, so it is absolutely right and imperative that Parliament has the time to focus on and debate the subject before final decisions are taken.

The headlines from our Committee report from yesterday are that, if Brexit goes wrong and there is no deal, or if we have too hard a Brexit, the results will be extremely damaging for patients; our health and social care services; Britain’s important and successful pharmaceutical industry; the supply and costs of medicines and vital medical equipment; our world-renowned scientific research base; the status of EU staff, who help to keep our health and social care services running; and UK nationals living or working on the continent, including British retirees, who depend on reciprocal arrangements to access healthcare.

It is fair to say that the majority of our Committee would rather we were not leaving the EU at all, or that, if we do, we stay in the single market and customs union. That was the near unanimous preference of all our witnesses, whether patients groups; charities; doctors, nurses and their representatives; the drugs companies, which do such vital work to develop and make available life-saving therapies and contribute so much to our economy; the manufacturers of vital medical equipment such as radioisotopes, which are used in the treatment of cancer; and our world-renowned medical research centres.

I thank my right hon. Friend for bringing this debate to the Chamber today. As many Members will know, my predecessor Baroness Tessa Jowell is campaigning, in the face of the cancer that she is dealing with, for greater international research and access to dynamic trials and new treatments for patients suffering from brain tumours. Does my right hon. Friend agree that Brexit puts at risk exactly that kind of international collaboration—that access to data sharing and to international scientific research—that patients suffering from brain tumours and many other conditions need to see move forward, not backwards? This is a grave threat from Brexit.

Before I call Ben Bradshaw, let me say that we have sufficient time, given the number of people who want to speak, but may I please ask that interventions are to the point and brief?

I absolutely agree with my hon. Friend the Member for Dulwich and West Norwood (Helen Hayes). I will develop that argument in more detail in a moment.

Our Committee also recognised that the Government have ruled out, so far, continued membership of the customs union and the single market. In the absence of a change of mind from the Government, the Committee concluded that the least damaging Brexit for our NHS will be for us to keep the closest possible regulatory alignment with the rest of the EU in the long term. A majority of the Committee would probably have liked our recommendations to be stronger on that and to include keeping open the option of an European economic area-type relationship in the long term. However, as Committee members we recognised that it is much more powerful for a Select Committee to agree a unanimous report, which ours is, rather than to disagree on a contested one.

Is the right hon. Gentleman able to say whether his Committee found anything that was positive about Brexit from a health perspective?

Not that I recall. Maybe when the Chair of the Committee, the hon. Member for Totnes (Dr Wollaston), contributes she will have better recall than me. The unanimity of the evidence we heard was very striking indeed.

As well as pursuing the closest possible regulatory alignment, one of our strongest recommendations to the Government is that they must be much more open and clearer about their Brexit contingency planning for a no-deal scenario.

We note and welcome the Prime Minister’s most recent statement that the UK will seek associate membership of the European Medicines Agency—although, given that, it is tragic that we are losing the EMA headquarters from London to the Netherlands. We also welcome the recognition shown by both the Health Secretary and his Lords Minister in their evidence of the importance of continued regulatory alignment with the rest of the EU. We noted that that was in contrast to the Foreign Secretary’s statement that medicines regulation is one of the areas where he would like to see the UK diverge from the EU. I am pleased that the Health Secretary at least won that argument.

However, we have serious concerns about the Government’s lack of a strategy for a no-deal scenario. The Government are still saying that they want a pick-and-mix, cake-and-eat-it relationship with the EU in the future. The image the Prime Minister used in her speech was of three baskets: full alignment in some areas, full divergence in others and something in between for the rest. But if the other 27 EU countries have made anything clear throughout this process, it is that that option is not available. We can have a Norway-style relationship, or we can have a Canada-style relationship, but we cannot have Canada-plus-plus-plus or Norway-minus-minus-minus. It is our choice.

I wish the Government well in their endeavours to achieve their pick-and-mix deal, but given the strong likelihood, if not certainty, that we will not get that, either Ministers will need to do the sensible thing and concede on the customs union and single market, or we will face the danger of crashing out on World Trade Organisation terms. Let me just spell out what our witnesses told us that would mean.

First, it would mean the seizing up of our medicines and medical equipment supply chains. We export 45 million patient packets of medicines a month to other EU countries and import 37 million. Any customs, regulatory or other barriers to this trade will affect supplies. Radioisotopes, for example, are vital in the diagnosis and treatment of cancer. They have a very short lifespan. Their smooth importation from the continent is time critical. The British Medical Association has warned that any disruption to this trade could lead to the cancellation of patient appointments, operations and vital radiotherapy treatment for cancer. Medicines and medical equipment would also become more expensive and there would be delays in getting them licensed and available for British patients. Switzerland gets access to new drugs 157 days later than the EU; Canada, six to 12 months later.

Secondly, we would suffer a further haemorrhaging of NHS staff who are EU nationals, exacerbating the staffing crisis that the NHS and social care face.

My right hon. Friend has made a powerful case about the risks of crashing out with no deal. Does he agree that uncertainty is a crucial factor in the NHS’s problems? Individuals want to plan their own lives, and the NHS wants to plan its staff. Many staff have said to me that they are concerned about the settled status process—when it will go live, what it will involve and whether it will be able to process applications quickly—and are making decisions on that basis.

My hon. Friend is absolutely right. The uncertainty not only bedevils business decisions, but is having a huge effect on the NHS, the pharmaceutical industry and the staff in all these sectors.

I represent the most remote constituency on the UK mainland. The recruitment and retention of qualified staff is a huge issue in my constituency. Does the right hon. Gentleman agree that a crash out, and the problems he outlines, will be even more emphasised in the north of Scotland?

Coming from a peripheral region, I completely understand the challenges that the hon. Gentleman and his constituents face and the difficulty that our health and social care systems already have in recruiting and retaining staff.

I will give the example of midwives. EU midwives provide care for 40,000 mothers in England every year. The Royal College of Midwives has reported that the number of EU midwives registering to practise in the UK has fallen “off a cliff’ since the referendum, and that at the current rate of loss there will be

“no EU midwives left in the UK within a decade.”

We must have a clear assurance from the Government that, whatever the deal or no deal, the vital flow of EU medical and other staff to this country will not be affected. EU nationals already here also need an absolute assurance that their current status and that of their families will not change.

Thirdly, we would suffer the relocation of significant parts of our pharmaceutical industry—one of Britain’s most important and successful sectors—to the continent. Indeed, as part of our inquiry we were told by GlaxoSmithKline and other companies that they have already spent tens of millions of pounds moving research and medicines licensing work to other EU countries as part of their contingency planning for a hard Brexit. That money would otherwise be spent on medical research in this country. It is investment that they told us will not come back.

Fourthly, UK citizens visiting or living in the rest of the EU, including a large number of British pensioners, could lose their eligibility for reciprocal free health care. If they could not afford to pay, they would be forced to fall back on our health and social care system. The average cost to the UK of a British citizen being treated in the rest of the EU is £2,300. The cost of treating a pensioner in Britain is almost double that at £4,500.

Our report highlights a lot of other areas where there will be a serious impact if we get Brexit wrong: the potential loss of European Reference Networks, access to and participation in clinical trials, research funding, the mutual recognition of qualifications and data sharing. The loss or diminution of any or all those areas would damage Britain’s leading role as a medical research centre and the cross-fertilisation of knowledge and expertise that is so important for medical advances and patient safety.

I know that many other hon. Members want to speak, so I will bring my contribution to a close. Before I do, it is important to note that there are areas that the Health Committee’s latest report does not cover: concern that future trade deals with countries such as America could open up the NHS to wholesale privatisation; the possible impact of diverging from EU standards on the environment and food safety on public health, which the Committee plans to return to later this year; and, most significantly, the economic and fiscal impact of Brexit and the knock-on effect on health and social care funding as whole.

We know from the Government’s leaked impact studies that all Brexit options will hit Britain’s GDP over the next 15 years by between 2% and 8%—that is, 2% if we stay in the single market and customs union, 5% for the Government’s preferred option, and 8% in the case of a no-deal scenario. Unless the Government propose to significantly increase taxes or borrowing, or to cut other public services to move money to the NHS and social care, that can mean only that there will be less money available for health and social care, and not the extra that was promised on the side of that bus.

All in all, the next few months of Brexit negotiations will be absolutely critical for the future of our NHS for years to come. Our constituents expect us to hold the Government closely to account, and we will.

It is a pleasure to serve under your chairmanship, Mr Stringer. It is also a pleasure to see the Chair of the Health Committee, my hon. Friend the Member for Totnes (Dr Wollaston). When my right honourable Friend, then the Member for Charnwood, Stephen Dorrell, stood down, I had the pleasure to chair that Committee, which I served on during the 2015 Parliament, and it was a great disappointment when I stood against my hon. Friend and she won. I will not tell hon. Members about how close the contest was, other than that she won handsomely and has chaired the Committee very well.

This is a sombre day: the anniversary of the death of members of the public and of PC Keith Palmer not very far from here. On that day I was too close for comfort; I will not forget it. I reflected then, and I reflect now, that luck plays a part in life. We are all lucky to be here today.

I want to focus on a section of this important report and on the Government’s response. I see the Minister in his place. He took over from my hon. Friend the Member for Ludlow (Mr Dunne), who was my Whip for a while. I want to focus on the future staffing requirements and on delays and cost.

The report states:

“The Government’s plan for our post-Brexit should…ensure that health and social care providers can retain and recruit the brightest and best from all part of the globe”.

On healthcare, we have to think beyond the European Union when we address Brexit, and I congratulate the right hon. Member for Exeter (Mr Bradshaw) on securing the debate and on his introductory speech.

The Committee reported:

“The Government must acknowledge the need for the system for recruiting staff to the NHS, social care and research post-Brexit to be streamlined to reduce both delays and cost.”

The Government’s response states:

“We are also boosting the domestic supply of staff through expanding training places and nursing and other areas.”

We have to focus on other areas. The thrust of my remarks is that if we are going to solve the ever-increasing problems of demand in the health service generally and have a better service post-Brexit, we have to broaden the base of practitioners; we have to look beyond doctors and nurses.

As part of that, we have to pay attention to regulation. The Committee addressed that under recommendation 10, which states:

“Attention needs to be paid to the balance between patient safety as served by regulatory rules which may restrict access to the profession... Regulation should not evolve into unnecessary bureaucratic barriers that inhibit the flow of skilled clinicians into the NHS.”

What we need to do post-Brexit is get more skilled people—health practitioners other than doctors and nurses—who adhere to properly regulated registers, into the health service, to reduce the demand on the doctors, nurses and other hard-pressed professionals who work there.

I refer my hon. Friend the Minister to the recent report by the Professional Standards Authority and the Royal Society for Public Health. The PSA regulates 31 occupations, including acupuncturists, holistic therapists, hypnotherapists and clinical technologists, as well as the Society of Homeopaths, the UK Council for Psychotherapy and many others. One of its key recommendations was that its 80,000 regulated practitioners should have the authority to make direct NHS referrals in appropriate cases, thereby reducing the administrative burden on GP surgeries.

I have tabled questions about whether Ministers have considered the report, and to date I have not had a positive response. I am sure that that is an oversight. However, I want to point out to my hon. Friend, and perhaps to the Chair of the Health Committee, my hon. Friend the Member for Totnes, that Harry Cayton, who chairs the PSA, is not happy that the report has effectively been ignored. For years we have been told that better regulation is necessary before additional practitioners can be given the opportunity to practise in the health service. As soon as better regulation appears, that seems to be of no consequence. The report was produced by not just the PSA but the RSPH. Where else do we go? The work has been done, and I should like to hear from the Minister about the important work on regulation done by the PSA.

I want to refer to two parliamentary reports. In 2000 the House of Lords produced a report on complementary and alternative medicine and set out to categorise a wide diaspora of services that were available in that field. It came up with a classification, and it is important that I run through it. In the top rank were five categories of what were known then as complementary and alternative medical practitioners. The report said they had to be considered independently in relation to the question whether they should be included in mainstream healthcare. The five were osteopaths, chiropractors, acupuncturists, herbal medicine practitioners and homeopaths. I shall run briefly through those in relation to their appropriateness for use in the health service.

I had the honour to serve in the 1987 Parliament, and at that time the mantra was, “The osteopaths are out of control.” It was all about one or two miscreants and why they needed regulation. Some of us organised a private Member’s Bill, and I served on the Committee that resulted, in the 1992 Parliament, when John Major was Prime Minister, in the Act of Parliament that regulates osteopathy—the Osteopaths Act 1993. Osteopaths are now regulated by Act of Parliament. Not only that, but they have brought the different colleges of osteopathy together so that they are regulated by one body.

Secondly, there are the chiropractors, who are also back manipulators. We got another private Member’s Bill through the House. That became the Chiropractic Act 1994. The chiropractors came together—the McTimoney chiropractors and the others—and were bound together under one regulatory body. They are regulated by Act of Parliament.

Before I go on to the third discipline, my hon. Friend the Minister should be aware that the number of people taking hours off work for lower back pain is the highest for all complaints. He would do well to make better use of chiropractors and osteopaths in the new landscape post-Brexit. That is something we have ignored, and now we are freed from the European connection, or will be—although we will obviously have links—we should look at it.

The third discipline that the noble Lords referred to was acupuncture, which is regulated by the PSA, and the fourth is herbal medicines, which has different forms of self-regulation. In the 2010 to 2015 Parliament, I was asked by my hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter), then Under-Secretary of State at the Department of Health, to work with Professor David Walker on a report on herbal medicine. We met as a Select Committee meets, for the best part of a year, to produce a report that recommended further improvement in regulation. That is something we need to return to.

The last discipline referred to was homeopathic medicine. Homeopathy is the most controversial of all the treatments I have described, but has had huge support in the House. In the 2006-07 Session, Rudi Vis, a former Labour MP, whose constituency I forget, put down an early-day motion in support of six NHS homeopathic hospitals. That was remarkable for two reasons. First, it attracted over 200 signatures, or one third of the House. Secondly, it was signed by the Secretary of State—not the former Secretary of State, but my hon. Friend the Minister’s boss. He signed it—here is his name on the motion. He is sympathetic to homeopathy. His problem is that he has been sandbagged by people such as the chief medical officer, who knows nothing about it. That is a major problem.

The early-day motion said:

“That this House welcomes the positive contribution made to the health of the nation by the NHS homeopathic hospitals; notes that some six million people use complementary treatments each year; believes that complementary medicine has the potential to offer clinically-effective and cost-effective solutions to common health problems faced by NHS patients”.

In subsequent Parliaments, other motions were tabled, and there was a change in approach—not by members of the public, but by a tiny, vociferous anti group outside the House, which launched attacks on Members who signed the motion. I took that to the Speaker as a breach of privilege. There was a motion backing homeopathy in—

Order. I have been listening carefully to the hon. Gentleman; he has referred his remarks back to the impact on the NHS of leaving the EU, but I think he is drifting a little. Does he think he could bring those remarks back to the subject before us?

I certainly can, Mr Stringer. I would be glad to. We served together on the Science and Technology Committee in the 2010 to 2015 Parliament, and you know my interest in this.

I will draw this all together with what is now a very important report. I have referred to the Lords report and said that there has been some doubt about complementary medicine. The reason the Government need to look at this post Brexit is the publication last week in The BMJ of a report entitled “Do NHS GP surgeries employing GPs additionally trained in integrative or complementary medicine have lower antibiotic prescribing rates?” More than 7,000 practices were surveyed—I will end on this point, Mr Stringer—and the report shows that there are statistically significant differences between the patient populations of surgeries employing integrated medicine and those of conventional GP surgeries. It is a properly formed report, and I suggest to the Minister that such treatments can reduce the cost and prescribing not only of antibiotics—we know that Dame Sally Davies published a book called “The Drugs Don’t Work”—but of other drugs.

In the post-Brexit landscape, the Minister has to look at a wider field. To ensure I stay in order, Mr Stringer, I turn to a question I asked the Secretary of State this week:

“Does my right hon. Friend agree that leaving the EU will be a good opportunity to build links with other countries’ medical systems, particularly those of the Chinese, who have, for instance, integrated Chinese medicine and western medicine to reduce the demand for antibiotics?”

The Secretary of State replied:

“My hon. Friend is right to draw attention to antimicrobial resistance because China is one of the big countries that can make a difference on that, and yes, we have had lots of discussion with Chinese Health Ministers about how we can work together on that.”—[Official Report, 20 March 2018; Vol. 368, c. 149.]

As a representative of Leicestershire, I found that significant, because Leicester’s hospitals have signed a memorandum of understanding with China—with a Nantong University-affiliated hospital—which expands a deal they already have to ensure greater research and training collaboration across the international medical community.

I have used Chinese medicine for years. I have no doubt that, post Brexit, when we have a better opportunity to strike deals and are no longer being hampered by the European Union’s restriction, we can bring those practices here. It would be good to set up a trial. Also, the Minister should look at the Indian Ministry of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy—AYUSH—which I will be visiting in September, to see how that wider base reduces healthcare costs in India.

When I was Chair of the Health Committee for a short time, I managed to get out a report on long-term care and conditions. About 15 million people in the UK have long-term conditions, which involve polypharmacy, or lots of drugs, and polymorbidity, or lots of problems. Many complementary therapies are effective in that context. That is another reason the Minister should look at them.

On Monday, the Secretary of State announced five new medical schools. Is the Minister aware of the time medical schools spend teaching the disciplines I have been discussing? In a five-year course, it is one hour. No wonder many doctors are reticent about such referrals, given that they do not understand the subject. Let us have a wider base of learning in the new medical schools so we have a better service in the future.

I have spent a long time in this House—30 years—and I have pretty much stuck to this subject right the way through. I think we are at a turning point with the report I have referred to, published in The BMJ, in which 7,000 practices are analysed. It blows out of the water the argument that there is no evidence. There jolly well is evidence, and if the Minister will only look at it, he can improve the quality of the post-Brexit health service, get better value for money, and bring people who have studied for years and who are out in the cold into the service. If he does that, we will have a much better situation than we have now.

Thank you for calling me relatively early in the debate, Mr Stringer. I apologise to hon. Members, particularly those on the Front Bench, because I will not be here for the closing speeches, but I will of course read them assiduously. I and some other MPs have a meeting with Imperial Healthcare Trust that has taken a long time to arrange. Given the pressures and crisis of funding in many parts of the NHS, I think I need to be there. It is not entirely irrelevant to the subject of the debate. I will, for the reasons I have given, try to be brief and confine my comments to the issues that affect my constituents.

I am extraordinarily privileged to have some of the finest healthcare and medical research facilities not only in this country, but across Europe and the world, in Hammersmith and Shepherd’s Bush. I have three of the five hospitals in Imperial Healthcare Trust: Queen Charlotte’s and Chelsea, Hammersmith, and Charing Cross. I also have, being built as we speak on a 23-acre site in White City, the major new campus for Imperial College. They are amazing institutions that this country is proud to have, and they are truly international in the staff who work there, their research and co-operation, and the funding that they receive. We cannot avoid the fact that they are grievously affected by the consequences of Brexit. They are resilient organisations and they will do what they can to mitigate the effects.

Just a few weeks ago, Imperial College announced a joint venture with the National Centre for Scientific Research, one of the major French scientific research institutions. There is already a lot of international co-operation, but one of the main purposes of the joint venture is to allow continued access to vital European funding. We welcome attempts to mitigate the effects of Brexit, but when we talk about Brexit it always seems to be about how we can achieve a second-best position. Like my right hon. Friend the Member for Exeter (Mr Bradshaw), who eloquently expressed the variety of damage that Brexit will do to the healthcare sector, I find it difficult to see any positives. Yes, it is possible to see mitigation, but very difficult to see how we are going to be any better off in any capacity as a result of Brexit.

Does my hon. Friend agree that, given the research facilities he has described in the hospitals in his constituency, we are talking about not only the effect on the institutions, but the ability of the entire health sector to produce the best outcomes for patients in this country, because they get new treatments faster because of the co-operative work being done internationally?

Yes, the system is fully integrated across EU countries, and the whole is greater than the sum of its parts.

Last November, the president of Imperial College, Alice Gast, revealed that some of the 2,000 staff at Imperial College who are EU nationals have already left. I will come on to why that should be the case, given what the Government have said on EU nationals. Half of them—1,000 people—have taken legal advice on their positions post Brexit. A quarter of the staff and a fifth of the students at Imperial are from the EU. In the healthcare sector across London there are 20,000 staff from the EU, which is about 15%.

A good example is another of my local hospitals, the Royal Brompton, where 30% of the clinical staff are EU nationals. I have visited the Royal Brompton, and it has the most extraordinary paediatric cardiac surgery unit doing the most advanced and delicate operations on newly born babies. When I visited, all the surgeons who were operating were EU nationals, I think from five different countries. The Government may say, “Well, so what?”, but I do not imagine that they maintain, as has been said previously, that we can give a sudden opportunity to replace many doctors and nurses with home-grown doctors and nurses. That is not going to happen overnight. We know that the demand is such that we will continue to rely on clinicians from abroad for the indefinite future.

My hon. Friend is making an incredibly valid point about staffing in our hospitals. My local hospital, St George’s, has already experienced a loss of staff because people from the EU are leaving. Our patients have to wait longer to be seen. For example, one lady who had to see a radiographer was seen within a day, but now she has to wait up to six weeks to be seen. Does he agree that what the Government say does not ring true in reality?

I agree with my hon. Friend. If Members are honest, that is the experience that many of us will have had. There are many questions about the health service, as I have indicated, and the situation is simply being exacerbated by removing one of the most compatible, professional and necessary parts of the health service: its staff from the EU27 countries.

Why are we losing those staff? We hear protestations from the Government that those who are here now and until 29 March next year are welcome to stay, but that is not correct. First, there is uncertainty, because nothing is agreed until everything is agreed. Secondly, the rights of EU staff will not be the same as they are now, as my hon. Friend the Member for Westminster North (Ms Buck) indicated in her intervention. There is no continuity of rights; settled status has to be applied for, there has to be a register and there might be identity cards. As often happens, certainly with people in medical research grades, they might leave the country for five years but want to come back, yet they would then no longer have settled status. The position in the transitional phase, we understand, will be different again.

Even if some legal certainty is eventually given, there is still the climate or mood among EU citizens. I can speak confidently about this, because more than 20% of my residents in Hammersmith are EU citizens—it is one of the top three boroughs in the country for the percentage of EU residents—so I talk to them every week. I have now talked to and corresponded with not hundreds but thousands of them over the past two years, and they are extremely concerned. Let us be honest: they have transferrable skills and they can go to work in countries where they feel more welcome and valued than they do here.

The Government have not done enough—indeed, the Government cannot do enough—to reassure those EU citizens. The message that Brexit sends is that they are at least not as welcome as they once were. I will end on this, which I came across when preparing for the debate. It is something that Imperial College Healthcare Trust put out shortly after the referendum, when it introduced #LoveOurEUStaff. The management wrote to the staff:

“Our country is currently in a place of uncertainty. There has been no clear message from the Government about what the future holds for EU citizens living in the UK… I’ve heard that many EU and other overseas citizens are feeling concerned about their futures in the UK. I’ve also seen the media reports of an increase in racist incidents following the referendum vote.”

Eighteen months on, I wish I could say that those comments no longer applied. Sadly, they do. The fact that we are barely nearer certainty in the matter means that every day individuals are voting with their feet, feeling that they will be more welcome and their skills more valued in other countries. Frankly, the Government are not doing very much to address that point. I, too, read the debate and hear what the Minister says about that. I wonder what the Government can do, given the hole that they have dug themselves into.

It is a pleasure and privilege to serve under your chairmanship, Mr Stringer. I thank the Backbench Business Committee for enabling this important debate, and the right hon. Member for Exeter (Mr Bradshaw), my friend and colleague from the Health and Social Care Committee, for his detailed and valuable contribution. He outlined the grave concerns that most of the Committee have heard and feel themselves on some of the issues relating to Brexit and the NHS. It is important to our Committee that the Minister is listening, that the report is taken seriously and that our recommendations are taken forward.

This is a solemn day. I echo the sentiments of other Members who have spoken. It is a year since we lost PC Keith Palmer, who sacrificed his life in preserving our democracy here at Westminster. My thoughts are very much with his family and with everyone who has been affected by that horrific attack on Westminster and our democracy. It is important that we also remember Jo Cox and her extremely poignant words: we do have much more in common than sets us apart. I wish to take those sentiments forward. No matter what happens, if we work together and take things forward constructively, there is always a positive way ahead to defeat extremism and terrorism.

I come to the topic of the debate. My constituents are finding it difficult to have continued interest in the Brexit debate, given how lengthy it has already been, but when it comes to the NHS that is entirely different. The NHS is fundamental to our values. I have never met anyone who has tried to say that it is not such a valuable institution or the bedrock of our society, or who does not greatly admire and understand the dedication of the NHS staff who serve us all so well. We all—our friends, family and ourselves—rely on the NHS at the most vulnerable points in our lives. The NHS is therefore different for most of our constituents across the United Kingdom. It must be treated with priority and preserved, and all steps must be taken to ensure that any impact of Brexit on our NHS is fully mitigated. We rely on the NHS, and we will continue to do so. The first point I make to the Minister is to emphasise the importance of our NHS.

My second point is on the workforce, which has already been touched on by many Members. I have been sent a report by the British Medical Association. I refer the House to my background as a psychologist, having previously worked in the NHS. There are real concerns about the workforce and Brexit. The BMA highlights in its report its concerns that highly skilled doctors and professionals will choose to leave the UK because of the ongoing uncertainty in the negotiations. Like other hon. Members, I think it is important that the Department reassure those staff about how valuable they are and about how much their contribution is wanted and needed moving forward. It is imperative that we continue to retain their services for our populations.

Quite astoundingly, nearly half of EEA doctors—45% of them—surveyed by the BMA in November 2017 said that they were considering leaving the UK following the referendum vote. Those are critical numbers. I believe that in England 7.7% of the workforce, or 12,029, are EEA graduates. The figure I have been given in Scotland is 5.7%, or 1,339—it is 8.8%, or 550, in Northern Ireland, and 6.4%, or 624, in Wales. These are high numbers of people working right on the frontline to preserve our healthcare and we need to make sure that they can continue to do that.

Some might say that there has been a shortage or a short-termism in our own training of medical staff, and that issue also has to be addressed in the future. However, it takes a very long time to train doctors and nurses. We must therefore consider the much-needed and valued services that we have at this time and at least for the next decade in relation to our staffing model.

The next issue I will talk about is mutual recognition of professional qualifications. The BMA is calling for the maintenance of reciprocal arrangements, such as mutual recognition of professional qualifications, after Brexit, which would enable professionals who qualified in one member state to practise their profession in another. So what are the Minister and his Department doing in relation to that issue? It seems crucial for the next decade or so that we maintain the workforce that we have and that we ensure we can continue to attract highly skilled professionals to come to the UK to work.

Reciprocal healthcare and the European health insurance card, or EHIC, have already been mentioned. It seems very important, particularly for people who have the most chronic illnesses and who are moving from the UK to the EU, or who are on holiday, and for those coming here from the EU, that we have some form of arrangement in that regard for the future. I must say that I have had some difficulties with the EHIC in the past, with my own family, in being able to utilise it appropriately in some countries. However, it is not until something is lost entirely that its merit and value are realised. I do not think that it has been a perfect system by any means. However, it is certainly something that we want to retain and ensure is still available to us in future, particularly for some of the most vulnerable people, who still wish to be independent and to travel but who may find it extremely difficult to afford insurance, and therefore might otherwise put themselves at risk.

The Committee heard a lot of evidence about life sciences when producing this report. I have been astounded by the evidence we have been given about just how world-leading our life sciences are. I have to say that that is not something I was acutely aware of, even given all my years in the NHS, but we have world-leading life sciences. We have some of the top researchers and we have been involved in, and leading, some of the most crucial clinical trials. We must ensure that we hold that position in future. That is a real issue, because there is a concern that if those who are very much at the top of their game in research are unable to continue to lead on clinical trials from the UK, they might seek to leave. We cannot allow that to happen, because it would plunge our world-leading life sciences sector into the depths.

I would really appreciate it if the Minister spoke about how we will maintain our life sciences at their current level and how we will ensure that our fantastic university hospitals—I have one in my constituency: Hairmyres hospital—continue to support the great research work they do alongside their clinical work, and that they have all the amenities and the top professionals they need in the future.

It was Rare Disease Day just a few weeks ago, and I took part in it. We sang outside Westminster tube station to raise awareness of rare diseases. Rare diseases are of course rare, so many people do not experience them. However, there are many types of rare disease, so it is quite usual that some of us will know at least someone who has experienced or is living with a rare disease. It is crucial that people with rare diseases participate in clinical trials, because we need them in order to make progress on prognosis and find the best treatments. We need to ensure that we maintain that collaboration with the EU, because otherwise patients on the ground will suffer.

Patients with rare diseases might already feel quite isolated; they will have few other people they can speak to who are experiencing the same difficulties or have the same diagnosis. However, they need to be included in clinical trials, which cannot be conducted in the UK alone. Will the Minister comment on how we will ensure that that collaboration continues, particularly on rare diseases?

On medications, the Committee heard evidence about time-sensitive supply chains and the potential risks to them. The need to ensure that sufficient stock is on the UK market could mean the stockpiling of those products, and manufacturers might not supply certain products to the UK until only a few weeks before they are needed, so the supply chain is crucial. This work is time limited. Distributors of medicines in the UK usually keep about 10 days’ worth of stock, but many manufacturers can stock medicines for up to four months in wholesale warehouses. How will that work, depending on the negotiated arrangement? We need to get medicines timeously to patients who need them—particularly, as has been mentioned, radioisotopes for those who suffer from cancer and other illnesses.

These issues are crucial. When I speak to constituents, Brexit seems like a hypothetical thing, way in the distance. However, as soon as we start to home in on what it will mean in their day-to-day lives for their health and wellbeing and that of their families, and for our NHS, Brexit comes to the front of their minds. That is why the Minister has the weight of the world on his shoulders, because he is required to take forward these vital issues for everybody who depends on the NHS and our services. I look forward to his reply. On medical radioisotopes, I led on the cancer strategy in the main Chamber just a month or so ago. It is vital that we get this right for our cancer strategy, to ensure that all the other work that it underpins can move forward in the way it is supposed to.

I will finish by briefly speaking about qualified persons, which is something I did not know much about before the inquiry. I am led to believe, from the evidence that we heard, that they are already a scarce resource. There has to be mutual recognition of the training of qualified persons between the EU and the UK, so that these qualified persons, who we need to ensure the safety of medications, remain in the country and can do that vital work. What progress has the Minister made on work relating to qualified persons?

I do not want to take up any more time, because other Members wish to speak, so I will end where I started. Brexit can seem like a concept that is not linked to our everyday lives. When it comes to the NHS, however, that is entirely different. It is crucial to all patients—it is crucial to all constituents, actually. It therefore falls to the UK Government to ensure that the very best outcome for clinical care is negotiated and achieved.

It is a pleasure to serve under your chairmanship, Mr Stringer, for the first time, I believe. I congratulate my right hon. Friend the Member for Exeter (Mr Bradshaw) on securing this debate and I thank all other hon. Members who have contributed and will contribute.

I have to declare many interests in this debate. Not only am I a patient of the NHS—not too frequently, I hope—but I also work in the NHS. I began my career as a medical student in 1991 in Newcastle and I spent thousands of days working in NHS hospitals, worked for many years as a GP, seen thousands of babies born in the NHS, helped to manage hundreds of good deaths and worked with thousands of colleagues, who are some of the most committed people one could ever hope to meet. My mum worked in the NHS as a nurse. My dad still works in the NHS, managing a practice. My partner works in the NHS and many of my friends work in the NHS. Tomorrow morning, I will be doing a GP surgery at the beginning of the day before working in my constituency and ending the day with an MP surgery.

My experience has taught me that it is the people who make the NHS, Mr Stringer. It is not just the ones whom politicians always talk about—doctors, nurses, paramedics and midwives. The NHS has amazing people working as laboratory technicians, physiotherapists, speech and language therapists, pharmacists, medical secretaries; people working in finance, planning, leadership, estates management, catering and cleaning. Add to that all the people who work in social care, providing care and support to people in their own homes, and in nursing and residential homes, and we have an army of people all dedicated to health and care.

Many of the people in that army do not begin their lives in the UK. We have always welcomed people—particularly, but not exclusively, doctors, nurses and midwives—from other parts of the world. In the last 20 years, the migration into the NHS from other EU countries has been significant, so that EU migrants now make up more than 5% of nurses, one in 10 of all hospital doctors and more than 5% of midwives. There are more than 60,000 EU citizens working in our NHS, giving their lives to helping our NHS. There are another estimated 90,000 EU citizens working in our social care system. Joan Pons Laplana, a Spanish nurse who has worked in the NHS for 17 years and just won the nurse of the year award, says that the uncertainty over Brexit is leading to EU citizens leaving the NHS. Whatever the Government say about EU citizens’ rights, their message is not yet getting through and it is not being believed. People are not hearing them.

Some 10,000 EU health workers have left the NHS since the Brexit vote. As my right hon. Friend the Member for Exeter has mentioned, there are enough EU midwives working in the NHS to staff around 12 maternity units. Between them, EU midwives provide care for around 40,000 mothers in England each year. There are 1,388 EU midwives as of September 2017, representing 5.4% of the workforce. But since the Brexit vote, the number of EU midwives coming has reduced and the number leaving has increased. There was a net loss of 183 EU midwives between October 2016 and September 2017. At that rate there would be no EU midwives left in the UK within a decade. This is happening right here, right now. It is a direct consequence of the Brexit vote.

Whichever way we look at it, the situation is bad. Between September 2016 and September 2017, there was a fall of 89% in new EU registrations to the Nursing & Midwifery Council, a drop from 10,000 people registering to just 1,000 in just one year.

It might be said that we should train our own nurses, not rely on nurses from overseas. I say to that yes and no: yes, we should provide more nursing and midwifery training placements, but changes to nursing bursaries have not led to any increases in placements offered by universities. At the moment, one in 10 nursing posts is vacant. What does that lead to? It leads to wards that might be a nurse down, putting pressure on the other staff, and hospitals having to spend billions of pounds on bank staff to fill the gaps. What does it mean for patients? It means having to wait longer for their appointment, no nurse being available when they are in pain and press their buzzer, and midwives being unable to give the one-to-one care that women deserve when they are in labour. When there are thousands of nursing and midwifery vacancies across the UK, we cannot afford to lose any staff.

The Government might say that they will guarantee the rights of EU staff already here, but that is not enough. Brexit is already making it less desirable for EU clinicians to come to the UK to practise. To limit the damage as much as possible, we need to keep the door open to EU staff and, more than that, we need to actively encourage them to keep coming.

This is not just about nurses; it is about doctors, too. The General Medical Council surveyed more than 2,000 European economic area doctors practising in the UK last year. More than half of them are considering leaving the UK, and 91% of those say that our decision to leave the EU was a factor in their considerations. Those are doctors, nurses, midwives and other important frontline clinical staff from EU countries doing an amazing job for our NHS whom we cannot afford to lose when the NHS is already under immense pressure.

Staff are important, but so is the money to pay them. We have already seen a slump in the value of the pound, making it less attractive for EU nationals to come and work here. That slump has also made it more expensive for the NHS to buy supplies and medicines; the Health Service Journal has estimated £900 million of extra costs each year. We have already seen our economic growth fall from the best in the G7 to the lowest. That reduction means less money for our country and less money for our NHS. Let us be honest: the NHS is not getting the money that it needs from the Chancellor of the Exchequer because when he looks at growth forecasts, he sees downward curves. He sees not enough money coming in to meet the growing needs of our ageing population. The lost growth that has already happened as a result of the Brexit vote is the equivalent of £350 million a week. That has already happened, and the future looks worse.

For the north-east of England—the part of the country that I represent—the Government’s own analysis of the impact of Brexit on the economy shows a reduction in economic output over the next 15 years. The Government’s analysis predicts that if we left the EU but stayed in the single market and customs union, we would grow by 2% less than if we stayed in the EU. It predicts 11% less growth even with a comprehensive trade deal and, if we end up with a no-deal Brexit, 16% less growth. That all means much less money for the NHS, not only now but for the next 15 years.

We have to ask, is it all worth it? This is not the deal that people thought they were getting when they voted to leave the EU. It is not the deal that my constituents in Stockton South, some of whom are here today, wanted, whichever way they voted.

If it were not enough that we have a staffing crisis being made worse by Brexit and a huge hole in our finances, we also need to look at the companies that work so hard to provide drugs and supplies for our NHS. Much of our medical research takes place together with European partners. More than 340,000 patients are enrolled in EU-wide clinical trials, with the UK leading the way in Europe for conducting clinical trials. We have the same set of rules for research as our European partners, and the same set of rules for adoption of new medicines. Together, we form a formidable partnership, representing almost one quarter of the global market for pharmaceuticals; alone, we are only 3%. If we separate from the European Medicines Agency but keep what the Government call “close regulatory alignment”, we will lose our influence and our leadership role in developing these systems and processes. We could end up a rule taker, not a rule maker. If we set our own rules that are different from those of the EU, we risk becoming de-prioritised for new medicines. As my right hon. Friend the Member for Exeter said, on average, Swiss patients get new drugs almost six months later than EU patients. We risk being excluded from clinical trials, for which data is held and co-ordination takes place at an EU level.

The supply chain for medicines and medical devices works now, but there is a risk that it will be disrupted if we leave the customs union. Do not just take my word for it; ask the members of the Association of the British Pharmaceutical Industry, made up of small and medium-sized enterprises working in our med-tech sector, which makes products that cross borders. They say they risk being put out of business by rising charges and more complex customs arrangements.

I am not doom-mongering about the future; this is happening now. The European Medicines Agency is already leaving the UK, taking with it 900 staff, about £300 million in taxable turnover each year, and the UK’s prestige from hosting such an esteemed organisation. The Committee asked Phil Thomson, president of global affairs at GlaxoSmithKline, how much his company had already spent on preparing for Brexit. He said that it was £70 million, which GSK would much rather have spent on cancer research. Those are the costs of Brexit to our NHS.

I know that nobody intended to harm the NHS by voting to leave the EU, but it is time to tell the truth: the NHS, which was already struggling, is now on its knees because of the Brexit vote. Brexit represents a threat to its very existence. Brexit should carry a health warning. Medical health experts—60 former presidents and chairs of medical royal colleagues, more than two dozen patient groups and healthcare unions—warned before the Brexit vote that this would happen. We are already experiencing a worsening of the staffing crisis and less money. In the future, less access to drugs and significant extra unnecessary challenges to research will collectively harm the NHS. Is it all worth it?

[Philip Davies in the Chair]

I join other hon. Members in paying tribute to PC Keith Palmer. It is a privilege to serve in this place, and an even greater privilege to be protected by courageous, selfless public servants such as PC Keith Palmer. It is tragic that he had to give his life to defend those working in and visiting the Palace. We will remember him, and are doing so today.

What the Government are doing in relation to Brexit, and what the prominent supporters of Brexit have inflicted on this country, is unpardonable. I get angrier and angrier as the ramifications of the decision become clearer. Hon. Members mentioned customs. If we do not get the seamless, frictionless deal that is promised, and small and medium-sized enterprises in this country that export to the EU are required to fill in a customs form, the Institute for Government estimates that that will cost them £30. That cost will add nothing whatever to those businesses.

The UK has been a major player in the European Aviation Safety Agency, but we are at risk of coming out of it. If we go back in, we will be subject to the European Court of Justice.

To bring the debate back to the NHS, what will Brexit do to the Institute of Cancer Research in Belmont, in a neighbouring constituency, and its ability to recruit staff and work co-operatively with other EU countries and institutions? I think this is unpardonable.

Yesterday, the Government made one of the very few of their announcements I have welcomed—the pay increase for staff. I intervened on the Secretary of State for Health and Social Care and asked about its impact on the recruitment and retention of EU staff, among others. Of course, as several hon. Members have mentioned, the NHS has been hit by a triple whammy. First, the UK is much less welcoming. That is a direct consequence of Brexit. Those who supported it, who say we are creating a global Britain, need to go out and talk to people and find out that we have left a perception of the UK as an insular country that does not welcome people from abroad. The value of the pound has gone down. Because the pound has crashed, it is much more attractive, particularly for nursing staff who used to come from places such as Portugal, Spain and Italy and remit money to their home countries to support their families, to work in Germany or France. Of course, we are in the bizarre position of choosing to make our trading arrangements with the EU much harder at a point when it seems that every single EU economy is growing faster than ours. We are at the bottom of the pile, so many of the citizens who would have come to this country to work in the NHS will see that their economies are growing faster than ours and that many more jobs are available in their home countries. Therefore, there is less inclination to come here. The NHS, like many other sectors, has been hit by that triple whammy.

Many Members have mentioned the impact on staffing levels, qualifications and retention, but I want to focus on one issue that I do not think other Members have mentioned. The Minister supported Brexit, and I want to understand whether he took into account the impact of our leaving the EU with respect to the falsified medicines directive. I suspect that there was not much small print behind that £350 million extra for the NHS every week, and it certainly did not include a reference to the impact of the UK coming out of the EU in relation to the directive. For those not familiar with it, an EU-wide system ensures that medicines used in the NHS are known to be genuine, rather than being something created in a sweatshop in India, which is not what the packet says. The system is about making sure that everything used in the health service in the EU is genuine, not falsified.

As I understand it, partly as a result of Brexit, the UK has not started building the database required. I see the Minister sending a note back to his officials. I hope that they know the answer. The work has not yet been started on the UK database, but it needs to be in place by February 2019. If it is not, we shall not have the guarantee that the medicines we use here are safe. The Government have apparently said that they definitely want to be part of the database or this arrangement, which is welcome, but it is not clear whether they want to be part of it after Brexit. We need to know immediately from the Minister whether they do want that, and whether the database will be in place by February 2019. If it is not, we shall be at risk of not being able to supply medicines that we are certain are safe.

This may of course be one of those cases when one of the famous red lines on the role of the European Court of Justice may have to be smudged a little bit. My understanding is that the database, and certainly the data within it, would be subject to the ECJ, and therefore if we want to be part of it we will have to swallow the fact that the ECJ will rule over the use of the associated data. That is just one small example of the many—probably millions—of different impacts that Brexit has had where we gain nothing. What we gain is additional cost. We are putting burdens on business. We are certainly not going to get any health benefits. The Minister will be alone in this debate, I think, in trying to find some silver lining in the Brexit cloud in relation to the NHS, because no one else has. He does not have any supporters there in his ranks weighing in behind him, saying “Brexit is brilliant for the NHS; Brexit is what we want for our healthcare.” It is solely on his shoulders. Of course, Mr Davies cannot weigh in, although I know he might be tempted to, but the Chair is not allowed to. So the Minister is alone. Even though he was a Brexit supporter, I suspect that even he does not actually believe that there is anything whatsoever to be gained by Brexit for the NHS.

Does the right hon. Gentleman think that it is significant that the only Conservative Back Bencher to come and speak in this debate focused his remarks almost entirely on the benefits he saw of importing Chinese and Indian homeopathic medicine to this country? Does that not give the impression that there is such a paucity of positive arguments that they were the only ones that anyone could come up with?

I think neither the right hon. Gentleman nor I would like to read too much into that contribution. I doubt very much whether it is established Government policy. The hon. Member for Bosworth (David Tredinnick) is very much an outlier in terms of his approach towards the health service generally.

Now that the Minister has had time to get some information on the falsified medicines directive, I hope he can provide some assurances that the UK will play a part, and will have a database up and running in time for us to be part of that, and he will swallow—although no doubt he was one of the people who said that over his dead body would the ECJ have any impact on us here—the role of the ECJ so that we can be a participant in something that is clearly beneficial from a health point of view, beneficial to patients and to the United Kingdom.

My final point is that the Department of Health and Social Care has asked Ernst and Young to conduct an assessment of the potential implications for the supply of medicines following the UK’s withdrawal from the European Union. As I understand it, that was started in March last year and I believe the work was finished in June. I may be wrong and I am sure the Minister will take pleasure in correcting me if I am, but if I am right, we are entitled to know when this is going to be published. We have a nasty suspicion, just as we did with the sectoral analyses and the impact assessments, that the Government are more interested in hiding the impact of Brexit from us than they are in making these reports public.

I am sure that that report would have gone into extensive detail about the potential implications for the supply of medicines following our withdrawal from the EU, and I doubt very much that it will have found anything very positive about those implications. If that report has been published and I missed it, I apologise, but if it has not, I hope the Minister will be able to set out when it will be published, and published in its entirety, so that we can all assess the impact of Brexit on the supply of medicines.

It is a pleasure to serve under your chairmanship, Mr Davies. I want to associate myself with the remarks made by colleagues about the tragic anniversary we are observing today.

If this Government deliver Brexit, we must negotiate a good deal for our healthcare institutions, our outstanding staff and us—the patients. I understand that we all have good intentions—no one here wants a bad Brexit deal—but I would like to hear from the Minister today how the Government’s stated intention to do no harm to the health service in each part of the UK is going to be delivered in practice.

We know already that the Government’s negotiating record in the talks is poor. After stating that we were going to take back control of our fishing industry, they have managed to deliver a deal for the transition period that no one—not one fisherman nor any MP—believes is in the best short-term interests of the industry. How will the Government ensure that we get a healthy Brexit deal for today, tomorrow and the future?

I am proud to have University Hospital Wishaw in my constituency. It is a large employer and provides healthcare across neighbouring constituencies as well. When patients use the facilities there, they want to know that they are getting the best healthcare possible. That is far more important to them than where their healthcare professional originally came from.

In preparing for the debate, I read reams of statistics and briefings from organisations representing medical professionals, such as More United, Healthier IN the EU, Scientists for EU, the Royal College of Nursing, the Royal College of Midwives, and the Royal College of Physicians and Surgeons of Glasgow, to name a few. All their research paints the same gloomy picture: EU and EEA doctors, nurses and other healthcare professionals who have left, and those who are considering leaving the UK, are leaving gaps in healthcare provision. There is also likely to be a crisis in social care as regulations tighten and people stop seeking work in the UK after Brexit.

It is incumbent on the UK Government, to which immigration is reserved, to ensure that healthcare professionals and social care workers from EU countries are encouraged and welcomed here, or there will be a serious drop in the high standards that patients expect from their NHS. The Scottish Government estimate that non-UK citizens account for approximately 5% of the NHS workforce in Scotland and around 6.8% of Scotland’s doctors. They have to estimate, as that data is held only at UK level because immigration is a UK matter. That seriously affects effective workplace planning by NHS Scotland. This issue needs to be addressed by the UK Government as a matter of priority.

Those EU nationals who want to stay and work in our NHS, and who want settled status, should be prioritised. It would be a real acknowledgement of what they do for our most vulnerable citizens if the costs of that process were met by the UK Government. The UK Government also need to ensure that there are regular reviews of the tier 2 shortage occupation list, so that specific staff shortages can be addressed. That should include medical research and the pharmaceuticals sector. We need to retain access to the best staff available, no matter where they come from.

Once Britain leaves the EU, we must retain frameworks and regulations that allow us to co-operate fully with the Medicines and Healthcare Products Regulatory Agency and the European Medicines Agency. That would allow for the smoothest transition, in terms of the authorisation of medicines for use in the UK, safety and pharmacovigilance. That is what patients and clinicians need. We also need a sufficient transitional period following the current negotiation process to allow for the development of robust, deliverable regulatory processes that do not disadvantage the UK and its citizens.

As has already been referred to, the Scottish life sciences sector is important. It employs 37,000 people, contributes more than £4 billion of turnover and £2 billion of gross value added to the Scottish economy, and is growing at around 6%. The life sciences sector in Scotland is distinct from the UK sector, in that med-tech and diagnostics companies comprise nearly half of it, with pharmaceuticals at 5%. The Government must take that into account in any future negotiations.

It is comforting to UK nationals who live in another EU country that, on the day the UK leaves the EU, they will still be eligible for the same healthcare as citizens there and will still be able to use the European health insurance card scheme when visiting another EU country. But what about UK citizens who, for example, require regular dialysis? Will leaving the EU mean that they will never be able to travel abroad?

We need to retain close links with the European Centre for Disease Prevention and Control. Potential pandemics will require the sharing of information. Notification of communicable diseases must not stop, and there has to be cross-border co-operation on those and other serious health threats.

Future trade agreements must not be allowed to impact on health and social care in Scotland. The Scottish Parliament’s European and External Relations Committee inquiry into the Transatlantic Trade and Investment Partnership, TTIP, stated:

“The protection of public services in Scotland, particularly NHS Scotland, was a key concern of those giving evidence to the Committee.”

Despite reassurances from the European Commission and the UK Government, the Committee remained

“concerned about the definitions of public services and whether the reservations contained in the final agreement would protect the full range of public services that are delivered in Scotland.”

We need to be clear that any future trade deals by the UK Government should explicitly address issues in order to protect the NHS from unintended consequences.

Out of a group of 60 or so proponents of the hardest of Brexits, not one is present to set out the pro-Brexit case for the NHS. They are not here, because they have no positive case to make. At its core, leaving the EU will damage the NHS and provide a worse service for patients.

Every step must be taken to protect the NHS across the UK from being hampered in its life-saving work. Patients deserve the best, and physicians, nurses, clinicians and those requiring social care should also get the best deal possible. Our life sciences, med-tech and diagnostic sector should be protected. We need to work with the EU on regulatory processes and disease prevention control. We must protect our most vulnerable citizens.

It is nice to see you in the Chair, Mr Davies.

I congratulate the right hon. Member for Exeter (Mr Bradshaw) on bringing this debate to Westminster Hall today. It is a very important debate, which is part of a much bigger debate going on in households and workplaces, such as the Vale of Leven Hospital and the Golden Jubilee National Hospital in my constituency.

Let me also associate myself with the words many have said about the loss of PC Keith Palmer last year. Due to their sacrifice, we are able to be here to debate today.

On some of the other Members who have spoken, I am sure it will come as no surprise to the hon. Member for Hammersmith (Andy Slaughter), who had to leave early, my hon. Friend the Member for East Kilbride, Strathaven and Lesmahagow (Dr Cameron), the hon. Member for Stockton South (Dr Williams), the right hon. Member for Carshalton and Wallington (Tom Brake) and my hon. Friend the Member for Motherwell and Wishaw (Marion Fellows)—for Hansard, what I say sounds like “Wishy” but it is spelt “Wishaw”—that I agree probably with everything they have said. As for the hon. Member for Bosworth (David Tredinnick), I am sure that they will appreciate I slightly disagree that inviting the People’s Republic of China into the NHS structure is the best way forward and a good argument for Brexit. We have already sacrificed the nuclear energy industry to that, and it is not going well.

Many people are quietly and rightly concerned about the impact of Brexit on our national health services—I say to Hansard that that is in the plural because there is more than one NHS structure in the United Kingdom of Great Britain and Northern Ireland—and their social care partnerships. Members have touched on that this afternoon, on the high numbers of EU nationals who are employed across those sectors and on the valuable contribution that those workers provide in areas across our communities.

In Scotland, EU nationals in the workforce are employed across all sectors. They play a critical role in our communities and in the NHS. Communities across these islands and the NHS health and social care systems have benefited greatly from the contribution made by staff and, yes, volunteers in those sectors from across the European Union. Citizens volunteer to gain experience, and a lot of EU citizens who engage with NHS structures across the UK have used volunteering to provide a service free of charge, so we must ensure their long-term futures are confirmed and not left in limbo.

To illustrate a point, I have been contacted by constituents who work in the NHS and its social care partners who are extremely worried by the manner in which the Government have approached the situation. They feel they are being used as political pawns in a game of chess where all the pieces have yet to be put out on the board. They have seen a lack of preparation in the Government’s approach to leaving the European Union. We should use this debate to celebrate the selfless individuals providing services within our NHS and social care partnerships. Instead, here we are having to protect them. If that is how EU nationals are being treated, as many Members have intimated today, what message does it send to people around the world, whether they are from Australia, India, Brazil, New Zealand or even the United States, who are considering bringing their skills, talents and enthusiasm to the NHS structures across the UK?

As a Scottish constituency MP, I hope that Scotland will at least strive to be a welcoming nation—I am sure the rest of the UK would as well—as we aim to attract the best talent to our universities and our health and social care workforce. From my perspective, the effects of Brexit will have a profoundly detrimental impact on that goal of being an inclusive society.

Since the creation of the NHS system, the world of medicine has moved on, and with growing patient needs, particularly from an ageing population, as well as the complex needs and conditions that are associated with that, we must ensure that our NHS structures and the interdependent health and social care partnerships have the ability to move with the times.

Some years ago, the Scottish Government, through the Scottish Parliament, passed legislation to integrate—quite early in the UK—the health and social care sectors to ensure a higher standard of care to meet the challenges of dealing with more complex population needs. That has been extremely beneficial for those delivering services, such as the NHS, local authorities, the third sector, which has yet to be mentioned, staff, and volunteers. More importantly, it is critical for those who rely upon the public service being delivered.

However, with the number of EU nationals moving to the UK declining and those already here anxious about their future, everyone in these islands could receive a double hit with the loss of talent of those who are qualified to work in both the health and social care sectors. There is also the issue of cross-border activity in health sector situations. That is not the border between the EU and the English channel or the North sea, but the one that everyone keeps forgetting: the land border of over 300 miles between the UK and the 500 million citizens of the European Union in the isle of Ireland. It shocks me that we have yet to hear about that in this debate.

We only need to go back to 2016 after the European Union referendum when Derry City and Strabane District Council, in conjunction with Donegal County Council, published the report on the impact of Brexit on Derry/Londonderry north-west city region, which was damning about the impact of Brexit on shared services, practical healthcare services, GP-led services and surgery services between County Donegal and the Strabane District Council region of Northern Ireland. It is shocking that that has yet to come up in the debate.

The people who work and volunteer in the NHS and those who rely on the NHS need assurances that services will not be harmed. I hope the Minister will be able to discuss some of that in their response and that patient care will not be downgraded. They need more than a simple slogan on the side of a bus.

Many of the challenges that the NHS structures and social care partnerships across the UK face, including those in Scotland, are not exclusive to the mainland of the UK. They also impact on Northern Ireland. The Government must take responsibility and action to fully assess the potentially damaging impact of Brexit on the delivery of health and social care. I look forward to the Minister summing up how the Government will answer many of the questions posed by me and other Members today.

It is a pleasure to serve under your chairmanship, Mr Davies. I join other Members who have expressed their remembrance and condolences to the families of those who died last year, particularly PC Keith Palmer. There was a very moving service in Westminster Hall this morning, which was a very fitting tribute to those who lost their lives this time last year.

I thank the Backbench Business Committee for securing this extremely important debate on one of the aspects of our exit from European Union that has not received the attention that I believe it warrants.

I congratulate my right hon. Friend the Member for Exeter (Mr Bradshaw) on the extremely clear way he introduced the subject. As someone who has served in the Foreign Office and as a Health Minister, before becoming a member of the Health Committee, he is perhaps more qualified than most to address many of the issues that we have discussed. He talked about the Select Committee report and how the wrong deal or no deal at all will be extremely damaging to the NHS in a series of ways, most of which I will touch on. It was also clear from his comments that there is a need for the Government to have a strategy in place to deal with the potential impact of no deal. It would useful to hear from the Minister on that.

I agree with my right hon. Friend about the loss of the European Medicines Agency to Amsterdam. It was a matter of great regret that we lost that wonderful institution. The fact that there were so many countries bidding to take it over shows how important it is to individual member states. My right hon. Friend set out some of the risks of no deal, leaving us on World Trade Organisation arrangements, with the potential risk of the seizing up of the medical supply chain. He also talked about staffing, which most hon. Members touched on. He gave the stark example of the number of midwives from the EU. If the current rate of attrition continues, we will have no EU midwives left in a decade. I remind hon. Members that we already have 3,500 midwife vacancies. He also talked about research and gave some clear examples of how investment is being lost now, before we have actually left the EU, and the impact on reciprocal care.

My right hon. Friend also touched on several things that were not in the report, but which are also important, such as the fiscal impact of our leaving, the potential risk to food standards and, of course, the risks from future trade deals. It is ironic that the NHS and other public services are specifically exempted from trade deals at the moment, as a result of agreements that we have with the EU.

We also heard from the hon. Member for Bosworth (David Tredinnick). I commend him for the ingenious way he got subjects of great importance to him into the debate, but I think that is probably the best I can say about the contribution, so I will move on. I am sure he will continue to fight for those things that are extremely important to him.

My hon. Friend the Member for Hammersmith (Andy Slaughter) spoke from his experience as a passionate campaigner on health issues in his constituency. He set out the importance of the NHS is in his constituency and his pride in what it has achieved. I would characterise what he said about the current situation for services in his constituency as a damage limitation exercise. He gave a startling figure about the number of EU staff who have already taken legal advice on their positions. That should be a very clear warning that uncertainty is still very much in the forefront of people’s minds. He set out well how staffing will be affected in London more than in other regions.

The hon. Member for East Kilbride, Strathaven and Lesmahagow (Dr Cameron) set out powerfully how important the NHS is and how people feel strongly about it in their hearts. She is right that we need to show staff how much we value them. She also set out the importance of reciprocal arrangements for qualifications and, indeed, for healthcare. She raised the importance of clinical trials, particularly in relation to rare diseases. I am sorry I did not get the chance to hear her singing the other week. She was absolutely right that there are particular risks for rare diseases and the development of new medicines. She was also right when she said that Brexit can seem a little abstract to people, but she and other hon. Members have set out in tangible ways how Brexit will affect many of the things that we hold dear.

It was a pleasure to hear from my hon. Friend the Member for Stockton South (Dr Williams), as always. He is one of those people whom we rely on in the NHS to keep the service going, and he rightly paid tribute to the whole range of professions, and the services provided by NHS staff. Of course, it is the staff who make the service what it is. He was right to say that the message is not getting through to EU staff about the future. We need to do more to reassure them. He clearly set out the gravity of the situation, in relation to the impact on staff. He was right to say that some impacts of Brexit are being felt now. GlaxoSmithKline provides evidence of that: about £70 million that could have been spent on cancer research being spent on preparations for Brexit was certainly a startling figure, and not one that we might expect to see on the side of a bus.

The right hon. Member for Carshalton and Wallington (Tom Brake) raised an important point about protections that we need to maintain against bogus medicines. I hope that the Minister will be able to provide reassurance about the falsified medicines directive. The hon. Member for Motherwell and Wishaw (Marion Fellows) talked about the importance of the Scottish life sciences sector and, in particular, its distinctiveness in relation to the sector in the rest of the UK. She also raised important issues about staff.

I want to say something about those from whom we have not heard today. As several hon. Members have observed, not one Back Bencher who campaigned to leave has come to speak in the debate. That is the same as in November when we discussed the future of the European Medicines Agency. No Back Benchers who advocated leave came along and spoke. There is a lack of ownership, candour and realism from people who campaigned to leave about the consequences of the vote and I would have welcomed a contribution from those Members.

The issues are, as we have discussed, of central importance. We have heard today how almost every aspect of the NHS could be affected by Brexit. Those issues were not articulated in the referendum, but whatever side of the debate people were on, no one, I believe, voted with the intention of causing damage to the NHS. It is our duty to vote according to our conscience, but we must make sure that when we leave the EU we do so in a way that protects and defends the NHS, which is so valued by so many, and that the Government will be held to account for the decisions that they take in the process.

Last year, more nurses and midwives left the profession than joined. Much of that is attributable to the way morale in the health service has plummeted in recent years. The exodus is even more pronounced among staff from the European economic area. As Members have mentioned, according to the Nursing & Midwifery Council, the number of EEA nurses and midwives joining the register decreased by 89% in the past year, while the number who left increased by 67%. That is exacerbating an already parlous situation. The NHS has about 40,000 nursing vacancies at the moment. To put things in terms that the Foreign Secretary might understand, we are missing enough nurses to fill 450 double-decker buses.

It is not just in nursing and midwifery that we face those issues. Figures from the Royal College of Physicians show that 9.3% of doctors working in the NHS are from EU member states, while, according to the General Medical Council, the number of new doctors coming from the EU fell by 9% last year. As the hon. Member for East Kilbride, Strathaven and Lesmahagow said, a survey of doctors showed that 45% of EU doctors were now considering leaving, with a further 29% saying they were unsure about the future. Given that 60% of junior doctors already report working on a rota with a permanent gap, and 45% of advertised consultant posts are not being recruited to, that is an extremely worrying position. A number of surveys have shown that one of the key reasons EU citizens are leaving is that they believe there is uncertainty about their future status. It is simply not good enough that the Government’s plans for migration will not be available until the end of this year.

I would be grateful if the Minister updated us, if he is able to, about when the immigration White Paper and Bill will be introduced. I also urge him, as I am sure other Members will, to be as loud and as clear as he can in reassuring EU staff in the NHS that they are valued and have a right to stay.

We welcome the fact that EEA citizens and their family members will be able to apply for settled status. How that will work in practice remains unclear and it is concerning that the new system will have issues, because when we look at the way the current tier 2 system operates, we see that it is hardly an exemplar of perfection. The Royal College of Physicians has stated that it is aware of 44 examples under the existing system whereby junior doctors have had certificates of sponsorship refused, due to increases in salary requirements. Will the Minister let us know what representations he is making on this particular issue and what the Government will do to try to solve this particular difficulty? Can he also reassure us that the new system that we have for EEA residents will not have similar problems?

In addition to the issues that I have raised about the potential impact on recruitment and retention, many hard-working NHS workers have also spoken about their concerns about impacts on their terms and conditions. As the Minister knows, at Health questions recently we discussed the increasing trend in NHS trusts setting up subsidiary companies. Of course, staff in those companies should be protected by TUPE regulations—legislation that is, of course, derived from the acquired rights directive. So I hope that the Minister can reassure those staff that there are no plans or intentions to water down TUPE regulations, and that they will be implemented in UK law in the form that they take now.

There is also a concern about other EU legislation and the possible threat to the working time directive, which provides safeguards not only for staff but for patients. I understand that last December various royal colleges wrote to the Prime Minister, asking for assurances that the directive would be implemented in UK law, but they have not had any such assurances.

We know from the most recent survey that around 60% of staff have concerns about their work-life balance, and they said that they were working unpaid additional hours, along with the increasing reliance on overtime in hospitals. It is important that we get a clear and unambiguous statement that the working time directive in relation to weekly hours will not be amended or watered down in any way.

Of course, the impact of Brexit will not just be on staff. If we do not secure the best outcome in the negotiations, there could be implications for access to treatments and reciprocal healthcare. As I said earlier, last November I spoke in Westminster Hall in a debate on the European Medicines Agency and it is fair to say that at that time there was some way to go before we had clarity about what the future arrangements will be, so I would be grateful if the Minister updated us today on any progress in that regard.

The Office of Health Economics recently set out just how stark the impact could be if a solution is not found in this area, because it warns that the average lag in submission for a marketing authorisation in the UK could be up to three months, that up to 15% of applications could be submitted more than a year after the EEA submission, and that some products may not be marketed in the UK at all. At the time of its analysis in January, the OHE found that 45% of applications had not been submitted to Australia, Canada or Switzerland following submission to the EMA, so can the Minister give us assurances that we will not be left behind when it comes to gaining early access to medicines and technologies?

In November, I also asked the Minister to confirm that Department of Health budgets would not be used to fund any additional Medicines and Healthcare Products Regulatory Agency costs. Again, we have not had any confirmation of that and again I would be grateful if the Minister provided reassurance in that respect today, as we know that NHS budgets are already extremely stretched.

As we also know, there are risks arising from the decision to withdraw from Euratom, simply because it falls under the jurisdiction of the European Court of Justice, because of course Euratom facilitates a free trade in nuclear material, including radioisotopes, and, as my right hon. Friend the Member for Exeter said, those materials degrade very quickly. They cannot be stockpiled, so it is essential that there are no delays to imports.

Is my hon. Friend able to say whether we will support the Euratom amendment that was passed in the House of Lords two days ago when it comes back to the House of Commons? That would be warmly welcomed on both sides of the House.

That is slightly outside my brief, but I understand the intention behind the question and hope that we will be able to come back on it positively.

There are concerns about the risks to patient care. Will the Minister set out how he expects us to address those?

The free movement of people was presented very much as a one-way street during the referendum. We know that about 1.2 million UK citizens live in other EU member states. There is a risk that if a similar arrangement on reciprocal healthcare is not implemented after we leave, that could impact on the arrangements those people enjoy. This could cause a huge amount of disruption for patients and health services. It will probably affect those with the most serious conditions most, in particular those with kidney failure who may not be able to travel in future if assurances are not gained. I would be grateful if the Minister updated us on that.

Finally, I would like to say a few words on the impact on social care. According to NHS Digital, it is estimated that about 7% of people in the social care sector, or 95,000 people, are EU citizens. That figure varies for different parts of the country. Recent estimates suggest that the social care sector will face a considerable staff shortage if EU migration is limited, particularly if visas are restricted on the basis of income. Projections from the Nuffield Trust suggest that there could be a shortfall of as many as 70,000 social care workers by 2025. Again, will the Minister set out what steps the Government plan to mitigate the potential impact on social care and staff? Can he assure us that we will have an immigration system that addresses staffing needs in the future?

Nobody voted to leave the NHS worse off. Nobody voted to reduce their access to treatments. Nobody voted to make themselves less safe if they require treatment. Nobody voted to reduce the number of staff in our hospitals. Yet all those scenarios are possible if the Government do not get the negotiations right. Members of all parties have expressed their concerns and the need for clarity. I hope that the Minister can now provide that.

It is always a pleasure to serve under your chairmanship, Mr Davies. May I begin my joining colleagues in remembering PC Keith Palmer and all those injured in the attack this time last year?

I congratulate the right hon. Member for Exeter (Mr Bradshaw) on securing the debate. He is a former Minister of State for Health. It is always interesting to hear from him both in his capacity on the Committee and with the experience he brings to the House on health issues. I also pay tribute to the Chair of the Health and Social Care Committee for the very informative report that was published this week.

I will start by addressing workers’ rights, which were raised by the shadow Minister. The Government have made it very clear that there is a commitment to protect workers’ rights and to ensure that they keep pace with changing labour markets. We do not need to be part of the EU to have strong protections for workers. The Government have a very strong commitment on that.

One of the key points raised by colleagues during the debate was the workforce. I am happy to respond constructively to the challenge set by the shadow Minister to send a strong message to EU staff within the NHS on how valued and essential they are. Healthcare professionals are internationally mobile. They are a key component of the NHS. There is consensus across the House on how valued they are as a part of the NHS, and that is very much part of the Government’s approach.

The NHS is a people business. Two thirds of what we spend in the NHS is on staff costs, so it is absolutely essential that there is a clear message to NHS staff. That extends to the people who are trying to re-run the referendum debate and go back to past arguments, who ignore the fact that, according to the latest figures, which go up to September 2017, there are 3,200 more EU nationals working in the NHS than at the time of the referendum.

There might be more EU nationals working in the NHS, but the number of EU clinicians has reduced. I believe that our points about doctors, nurses and midwives are still valid.

There has been a slight reduction in nurses; the situation is more textured for clinicians as a whole. The hon. Gentleman did not touch on the fact that there are almost twice as many doctors from the rest of the world than from the EU. The NHS recruits internationally, and that will still be the case after Brexit. The Prime Minister has signalled repeatedly that the UK will be open to the brightest and best, and that will continue to be the case regardless of the deal we do.

Looking to the future, doctors from outside the EU are currently subject to a strict regime, and at the moment the demand for sponsorship certificates showing that an NHS trust wants to employ a doctor seems to exceed the supply. Will doctors from the EU who want to come to our country post Brexit be subject to the same regime, or does the Minister envisage a different regime? What representations is he making to the Home Office about that matter as we look forward to the immigration Bill?

Of course we are making representations to the Home Office, but the Prime Minister has signalled our commitment to attracting the brightest and best, and that will continue. What has been negotiated so far probably gives the hon. Gentleman the best signal. What the Prime Minister announced in December and what my right hon. Friend the Secretary of State for Exiting the European Union announced this week about a transition deal actually protects the rights of EU citizens. That underscores the Government’s commitment to ensuring that a positive message is sent to EU staff in the NHS.

I thank the Minister for giving way and apologise for not making a fuller contribution to this important debate; I had a long-standing commitment as Chair of the Health and Social Care Committee that could not be delayed.

On the workforce, will the Minister comment on a small area that the Committee highlighted in its report but which many people are not aware of: the role of qualified persons? That is the individuals who are legally responsible for batch-testing drugs before they are released on to the market or made available for clinical trials. Will he pay close attention to the problems that will arise and the impact on clinical trials and the safety of medicines if qualified persons are no longer recognised in the UK after it leaves the European Union? That workforce is in great demand, and there is clear evidence that many of them will have to leave to the EU if that happens, leaving Britain short.

I am very happy to recognise my hon. Friend’s point, which is well made. As she knows, I am keen to have close discussions with her about such issues. However, through our adoption of the acquis into UK law, our desire for a transition deal, our protection of workers’ rights and our clear signal to EU citizens, the Government have signalled that we are committed to working collaboratively with the EU and to maintaining high standards. Indeed, science and healthcare is one of the areas where collaboration is best and where the EU has the strongest desire to maintain that collaboration. We work from firm foundations as we take on some of these specific issues, which the Department will continue to explore.

At the same time as attracting talent from overseas—from both the EU and beyond—we should not lose sight of the importance of growing our own workforce. Again, the Government have clearly signalled our intention in that regard, with a 25% expansion of undergraduate places for nursing and our announcement earlier this week of five new medical training centres, in Sunderland, Lincoln, Lancashire, Chelmsford and Canterbury. There is a clear desire to strengthen training for the existing workforce.

That sits alongside other initiatives, such as apprenticeships and ensuring that there are different pathways for people to progress in the NHS. That will ensure that people can develop their careers at different stages, so that someone who enters the system as a healthcare assistant, for example, is not trapped in that role but is able to progress through the nursing associate route and go on to be a qualified nurse. There are myriad ways in which we need to ensure that the NHS has the right skills.

That brings me to my hon. Friend the Member for Bosworth (David Tredinnick), who talked about broadening the base of practitioners, an issue on which he has campaigned assiduously for many years. I agree that we do need to broaden the base. That must always be addressed in an evidence-based manner. He cited an interesting BMJ report. However, initiatives are already under way to look at how we have a broader base and more of a multidisciplinary team, for example with physician assistants working alongside GPs in addition to nurses. The issues he raised speak to that.

The hon. Member for Hammersmith (Andy Slaughter) referred to people leaving. In fact, he said that people are voting with their feet, but that is slightly at odds with the fact that there is a net increase in EU staff. It is important that we in this House do not give a sense of negativity or rerunning past arguments on the referendum but start to look forward and reassure people on how much they are welcomed.

A point that came out of remarks by the right hon. Member for Exeter and a number of colleagues in the debate was about the life sciences industry. Again, one did not really get a sense of the reality. The reality is that last year London secured the most investment of any city in Europe—that is post-referendum. Therefore, the doom and gloom and sense that everything is drifting from our life science industry—

I do not know the precise date but, having come to the House from a corporate career, I know that decisions can usually be stopped if there is a concern. The gestation is often for a longer period, but that does not mean that the decision cannot be stopped. The right hon. Gentleman may be able to point to one or two decisions, but there have been a number of significant decisions in the life sciences industry. I look at the investment in Oxford and Cambridge and, for example, the commitment of the Bill and Melinda Gates Foundation and its significant investment in the life sciences industry. I also look to the work that my hon. Friend the Member for Mid Norfolk (George Freeman) has done on the life sciences industry in terms of the golden triangle of London, Oxford and Cambridge. This is a sector that we should be championing, not talking down.

There has been significant investment in the life sciences industry in the past 12 months. It is perfectly valid for colleagues to raise concerns and to recognise the need for the Department to reassure and address specific issues as part of our planning for Brexit. However, it is misleading to suggest that this industry is not thriving when we see the highest investment in Europe coming to the UK, we see 3.5% of the global market coming into the UK and we see Oxford and Cambridge—the golden triangle, as it is termed—thriving in the way we have seen in recent months. Kent Council has been getting in on the act with NCL Technology Ventures, which has put further money into forward-looking medical technology. Even local authorities are recognising the benefits of investment in the life sciences. International and domestic investors are coming together in this area. It is beholden on us in these debates to better reflect the reality of what is happening.

I am always keen to listen to the hon. Member for Stockton South (Dr Williams), who always speaks with authority on medical matters, not least as he is a practising clinician. However, on this occasion I fear he strayed into Treasury matters when he started to talk about the UK growth forecast diminishing. As a former Treasury Minister, I was particularly interested in his remarks, and I gently point out that they were at odds with the Office for Budget Responsibility. The OBR is clear that the growth forecast for 2019 and 2020 is 1.3%. That rises to 1.4% in 2021 and to 1.5% in 2022. The OBR recently improved its growth forecast.

I agree that I am straying into Treasury matters, but I have read the IMF’s forecasts for the UK economy for 2019, which were downgraded from 1.6% to 1.5%, when many of our closest partners, including the United States, Germany and Canada, were upgraded. I have also seen that the UK’s economic growth has fallen from the highest in the G7 to the lowest. That has all happened since our decision to leave the European Union. Is it not true that the IMF predicts that our economic growth will be less than it would have been if we had not made that decision?

We can see the variability of forecasts, but the OBR’s forecast, which is the one that really matters—there is consensus that the Government rely on it and that Government planning is undertaken on the basis of it—shows a clear trajectory of improvement that is not reflected in much of the doom and gloom that we have heard in recent weeks. The debate is better informed if we tie it into the benchmarking that the Government use when setting fiscal policy.

The hon. Member for East Kilbride, Strathaven and Lesmahagow (Dr Cameron) commented on the fact that her constituents are bored by the length of the Brexit debate. I am sure that if anyone is watching the debate, that will resonate with them. That is why it is so important for us to look forward. We should look at the areas of real concern where the Department needs to focus, such as maintaining the regulation and considering the mutual recognition of qualifications, which is a real issue that we want to make progress on with the European Union, because it is of concern to people. To look constructively at how we address some of those issues is far better than having groundhog day on the same areas.

Given the evidence we heard, and given that I have emphasised how critical the NHS is to the public and that it is a key priority for Brexit, I am perplexed that the Secretary of State for Health and Social Care does not have a place at the Brexit table in Cabinet. Far be it for me to try to elevate him even further, but the NHS is crucial and pivotal and deserves to be at the core of Brexit.

The hon. Lady is right to recognise the skills and talent that the Secretary of State brings to this debate as to many others. It is no coincidence that he is the second-longest serving Secretary of State for Health. It would be recognised across the House that it is a demanding job. It is to his great credit that he has been in post for such a period and that he has championed patient safety in the way that he has, which the shadow Minister has generously recognised on occasion.

The Secretary of State’s role in Government was further signalled and underscored by the Prime Minister in the recent reshuffle, when the responsibility for social care was added to the Department. As the debate has reflected, social care, and how we address it from an immigration perspective, and from a training and upskilling perspective, is one of the key legitimate areas of the Brexit debate. We are focused on that in our discussions with the Home Office and others.

The hon. Member for Motherwell and Wishaw (Marion Fellows) picked up on the need for a transition period. That point reflects the fact that the Government are listening and have responded constructively. I know from my previous role in the financial services sector in the City that there is a strong desire for a transitional period. That point was also raised by many in the healthcare sector. It is to the great credit of the Secretary of State for Exiting the European Union that those discussions have been conducted in such a constructive way. There has been a lot of doom-saying and negative commentary—“Nothing will be agreed; it won’t work.”—but he has assiduously stuck to his task. While there are some formal processes still to be completed, significant progress has been made on a transition deal, and there is reasonable consensus that it is constructive.

Several colleagues mentioned the impact of leaving Euratom. I simply remind the House that there is nothing in the Euratom treaty that prevents materials from being exported from an EU member state to countries outside the EU, nor do those materials fall into the category of so-called special fissile material, which is subject to nuclear safeguards. We very much recognise the short half-life of medical radioisotopes and the need for rapid delivery, but again there is much that can be constructively done.

The shadow Minister mentioned subsidiary companies. I do not want to incur your displeasure by straying too far from the subject of Brexit and into subsidiary companies, Mr Davies, but as the shadow Minister raised that point, I feel it is appropriate to address it. He asked what TUPE protections there will be. There are TUPE protections now and the Government have absolutely no intention to change that.

For those who sometimes suggest, as Opposition Members occasionally do, that subsidiary companies within the NHS is a form of privatisation, I merely remind the House that this legislation was passed in 2006 under a Labour Government. I was not in the House at the time, but I do not recall—this may be one for those connoisseurs of Hansard—that it was presented by Labour Ministers as a way of achieving privatisation in the NHS. Subsidiary companies are 100% owned by their parent company, which is the NHS family, so they stay very much within that.

Since the Minister has gone in that direction, I ask him again specifically: if it is such a good idea, would it be a good idea for NHS trusts that propose setting up subsidiary companies to publish their business plans so we can see what is happening with that public money?

I am a former member of the Public Accounts Committee. The then Chair, the right hon. Member for Barking (Dame Margaret Hodge), would always talk about following the public pound. The National Audit Office has considerable reach in doing that.

My point is that subsidiary companies are within the NHS family. They are 100% owned by the NHS foundation trust that sets them up. They are a better vehicle than the alternative of contracting out, which gives far less grip over how services are provided. The legislation passed by a Labour Government is welcome. We should not re-write history and suggest that legislation that was fine in 2006 should suddenly be presented as privatisation.

That goes to what we sometimes see in the Brexit debate—I will bring this back to the Brexit debate, Mr Davies—in terms of a trade deal with the US. We are sometimes told that a trade deal with the US in a Brexit context is alarming and somehow a threat to the NHS, often by the same people who are very positive about the EU. When TTIP was being debated, the EU lead negotiator said TTIP was not a threat to the NHS.

If there is no threat from a trade deal with the United States, will the Minister rule out the possibility of United States pharmaceutical companies gaining the ability to market directly their products to UK patients in any future trade deal?

My point is that we will have control of our trade deal. The Prime Minister has made it clear that there will be no change in the protections afforded to the NHS. The subject of the debate is Brexit, and we are talking about the difference between being inside and outside the EU. The regulatory controls as they would have been under TTIP will be no different in the new landscape.

I remind the hon. Gentleman, who was very critical of Brexit, that more than 61% of people in Stockton voted to leave the EU. He might think that his voters are misguided and wrong, and that they made a huge error in how they voted, but I hope he agrees that it is right that the Government respect that democratic decision and deliver control over our trade policy.

The Minister will appreciate that Northern Ireland voted to remain in the European Union. He seemed to hop, skip and jump over the issue of the border. Will he clarify today, or in writing to Members who are participating in this debate, that the common travel area will extend to a member of NHS staff working in Northern Ireland who happens to be a Romanian or French citizen but lives in the Republic of Ireland, and that they will not be forced to become a citizen of the Republic of Ireland or the United Kingdom after Brexit?

I am very happy to write to the hon. Gentleman about that. The question of the border is for deep negotiation with our European partners. There is a desire on both sides for us to get it right, particularly given the sensitivities in Northern Ireland.

Will the Minister comment on the need for contingency planning, which is one of the central themes of our report? As he knows, nothing is agreed until everything is agreed, and there is genuine concern that we could have a last-minute no-deal scenario, which would have major implications for supply chains in the life sciences industry. Will he confirm whether he will publish a detailed list of the areas in which contingency planning is taking place? Will he also publish the detailed contingency planning?

The Chair of the Committee is absolutely right about the importance of contingency planning. In the Scottish context, on the steps of No. 10 recently, a critic of the Government as fierce as the First Minister praised the level of discussion between the devolved Government in Scotland and the UK, and her discussions with the Prime Minister.

It may reassure my hon. Friend to hear that the Department has secured additional funding from the Treasury—more than £20 million—as part of our preparation for Brexit. The right hon. Member for Exeter has previously asked in the House whether the Department’s preparation and staff resource are at the level that he and other colleagues seek. That is a fair observation, and the situation is continually being improved. Alongside that, considerable work is going on within the wider NHS family—in NHS England, NHS Improvement and elsewhere.

Like the Prime Minister and the Secretary of State, I emphasise once again the importance of EU staff within the NHS. They are hugely valued and will continue to be so, and we are keen to protect their workers’ rights. That is reflected in the agreements reached by the Prime Minister in December and those reached earlier this week by the Secretary of State for Exiting the European Union. Alongside that, considerable work is going on within the Department to address a number of these issues as part of our contingency planning. We continue to seek a very close co-operative deal with our partners in the European Union. In areas such as science, there is a long and strong tradition of working in such a collaborative manner. As part of continuing those preparations, this debate and the Committee’s informed report provide much material on which we can work.

I thank all colleagues who took part in this extremely important and valuable debate. The Minister suggested that the contributors had a rather doom-and-gloom approach, but all we were doing was reflecting the evidence we heard in the Committee’s inquiry. Other Members were reflecting the concerns that had been raised with them by a wide range of professional health organisations, staff bodies, royal colleges and so forth. We are simply the conduit of their concerns.

If I may criticise the Minister, I found what he said a little Panglossian on the dangers and threats, and people’s worries, that we highlighted in our report. I should have liked to hear him say a little more about the vital importance of regulatory alignment. I hope he will think about that and study the report carefully.

Like the Chair of the Committee, I would like the Government to be much more transparent about their contingency planning. The Minister may feel confident that the UK Government will achieve their desire of a pick-and-mix, cake-and-eat-it deal with the European Union, but not many people share that confidence, so in the end we shall have one of two stark choices. It is important that the public should know the choices before Parliament and that the public take a final view.

The Minister has been in the job only a couple of months. I have huge respect for his ability and his record in other Departments, so I hope he will spend some of the Easter recess reading not only our report, if he has not read it already, but some of the evidence given to us by organisations. I hope that will inform him and his ministerial colleagues in fighting the NHS’s corner in the context of the negotiations in the next few months. I hope he will listen to and engage with some of the organisations that have been speaking to us.

The Minister is right: the Government have listened on transition, which we welcome. The sectors we have been talking about today welcome it too. Of course, the transition is basically a status quo. Essentially, nothing is going to change. What worries me is that we are simply delaying. We are putting off the evil day when the difficult choices, hard decisions and potential damage have to be faced. It is a delay rather than a solution. In the next few months, we will have to have much clearer answers from the Government about the final end state and solution. Otherwise the concern and uncertainty will go on.

I thank the Minister for his response, other hon. Members for taking part, and you, Mr Davies, for being in the Chair. I am grateful that the Backbench Business Committee gave us the time for the debate.

Question put and agreed to.


That this House has considered the effect on the NHS of the UK leaving the EU.

Sitting adjourned.